Cardiopulmonary Resuscitation (Basic and Advanced Cardiac Life Support) David Maldonado MD Mayo Clinic Rochester, MN, USA Agenda • Cardiac Arrest • Basic Life Support • Advanced Cardiac Life Support for Pulseless Arrest • Ventricular Fibrillation (VF) • Pulseless Ventricular Tachycardia (VT) • Asystole • Pulseless Electrical Activity (PEA) • Algorithms Cardiac Arrest • Sudden loss of heart function • With or without prior history of heart disease • • May lead to death within minutes In U.S up to 750,000 cardiac arrests with attempted resuscitation every year • 225,000 deaths Causes of Cardiac Arrest • Most commonly coronary artery disease • Electrical impulses become too rapid (ventricular tachycardia) or chaotic (ventricular fibrillation) • Also from profound bradycardia, respiratory arrest/choking/drowning, electrocution, trauma and other causes • May also occur without any known cause Americanheart.org • Brain death begins within 4-6 minutes • Cardiac arrest can be reversed within minutes • Chances of survival decrease 7-10% every minute without CPR or defibrillation (not including cold-water drowning) • Early & effective CPR and early & appropriate defibrillation are keys to management Americanheart.org Cardiopulmonary Resuscitation (CPR) Basic Life Support (BLS) • Chest Compressions and Rescue Breathing for person felt to be in cardiac arrest • To provide blood flow to brain and heart • Maintain end-organ perfusion during arrest • May still likely require defibrillation or definitive treatment of ACLS (anti-arrhythmic medications, fluid resuscitation, electrolyte restoration, etc.) BLS Healthcare Provider Algorithm No movement or response Open AIRWAY, check BREATHING If not breathing, give BREATHS that make chest rise If no response, check pulse: Definite pulse • Give breath every to seconds • Recheck pulse every No pulse Give cycles of 30 COMPRESSIONS and BREATHS minutes Push hard and fast (100/min) and release completely Minimize interruptions in compression AED/defibrillator ARRIVES Shockable (VF/VT) Check rhythm Shockable rhythm? Give shock Resume CPR immediately for cycles Adapted from Circulation;112 (24 Supplement): IV-19 (2005) Non Shockable Resume CPR immediately For cycles Check rhythm every cycles; continue until ALS Providers take over or victim starts to move ABCD’s of BLS Step 1: Airway • Head-tilt, Chin-lift maneuver • Open airway Step 2: Breathing Look, listen, and feel • • • • Look for chest rise Listen for normal breath sounds Feel air flow with cheek or hand If not detected within 10 seconds, give rescue breaths, then proceed to next step • Each breath for second • Visible chest rise • Bag-mask, mouth-to-mask, mouth-tomouth Smurd.com Step 3: Circulation Check Pulse • Pulse present: give breath every 5-6 seconds • Pulse absent: deliver effective chest compressions • “Push hard and fast” • 100 compressions/minute • 4-5 cm depth • Complete chest recoil • 30 compressions : breaths = cycle Chest Compression Technique Smurd.com 100 compressions/minute Abella et al Circulation 2005;111:428-434 Compression Depth 4-5 cm Edelson et al Resuscitation 2006; 71:136145 Step 4: Defibrillation Advanced Cardiac Life Support (ACLS) • Oxygen, monitor/defibrillator, IV • Assess rhythm • Shockable rhythm • Ventricular fibrillation • Pulseless Ventricular Tachycardia • Non-shockable rhythm • Asystole • Pulseless Electrical Activity Shockable Rhythms VF and pulseless VT • Deliver single shock (360 J Monophasic or 200 J Biphasic) • Immediate cycles of CPR • Assess rhythm – Still shockable rhythm? • Repeat defibrillation, cycles of CPR, and either epinephrine 1mg every 3-5 minutes or Vasopression 40 Units IV x • Assess rhythm – Still shockable rhythm? • Repeat defibrillation, cycles of CPR, and consider antiarrhythmics • Amiodarone 300mg IV push or • Lidocaine 1-1.5mg/kg Non-Shockable Rhythms Asystole and PEA • Immediate cycles of CPR • Epinephrine 1mg IV every 3-5 minutes or Vasopressin 40 Units IV x • • • Atropine 1mg IV for asystole or slow PEA Reassess rhythm – Still non-shockable? Repeat pattern and consider differential Differential/Management H’s and T’s • • • • • • • • • • • Hypovolemia Hypoxia Fluid resuscitation Supplemental O2 Hydrogen (Acidosis) Treat cause, ?bicarbonate Hypo-/Hyperkalemia Correct imbalance Hypoglycemia Check/replace glucose Hypothermia Rewarming Toxins Toxin-specific Rx Tamponade Pericardiocentesis Tension Pneumothorax Needle decompress Thrombosis (MI or PE) MI/PE Rx Trauma Surgical evaluation Post-resuscitative Care • Supportive, multi-organ care • ?Hypothermia, ?Glucose control • Predictors of poor outcome at 24 hrs • Absent corneal reflex • Absent pupillary response • Absent withdrawl response to pain [...]... effective chest compressions • “Push hard and fast” • 100 compressions/minute • 4-5 cm depth • Complete chest recoil • 30 compressions : 2 breaths = 1 cycle Chest Compression Technique Smurd.com 100 compressions/minute Abella et al Circulation 2005;111:428-434 Compression Depth 4-5 cm Edelson et al Resuscitation 2006; 71:136145 Step 4: Defibrillation Advanced Cardiac Life Support (ACLS) • Oxygen, monitor/defibrillator,... 1-1.5mg/kg Non-Shockable Rhythms Asystole and PEA • Immediate 5 cycles of CPR • Epinephrine 1mg IV every 3-5 minutes or Vasopressin 40 Units IV x 1 • • • Atropine 1mg IV for asystole or slow PEA Reassess rhythm – Still non-shockable? Repeat pattern and consider differential Differential/Management 6 H’s and 5 T’s • • • • • • • • • • • Hypovolemia Hypoxia Fluid resuscitation Supplemental O2 Hydrogen (Acidosis)... Activity Shockable Rhythms VF and pulseless VT • Deliver single shock (360 J Monophasic or 200 J Biphasic) • Immediate 5 cycles of CPR • Assess rhythm – Still shockable rhythm? • Repeat defibrillation, 5 cycles of CPR, and either epinephrine 1mg every 3-5 minutes or Vasopression 40 Units IV x 1 • Assess rhythm – Still shockable rhythm? • Repeat defibrillation, 5 cycles of CPR, and consider antiarrhythmics